Provider Demographics
NPI:1871134759
Name:HECKERT, MELANIE
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:HECKERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 STATE ROAD 167
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53076-9603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17345 W CAPITOL DR STE 103
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2005
Practice Address - Country:US
Practice Address - Phone:414-202-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11251-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11251-146OtherMASSAGE THERAPY LICENSE